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Wang LJ, Collazo-Maldonado R. Something Out of Nothing: A Rare Case of Pulmonary Renal Syndrome With Pauci-Immune Glomerulonephritis and Diffuse Alveolar Hemorrhage With Negative Serologies. Cureus 2021; 13:e18614. [PMID: 34765369 PMCID: PMC8572681 DOI: 10.7759/cureus.18614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/11/2022] Open
Abstract
Background: Pauci-immune crescentic glomerulonephritis (CrGN) is one of the most common etiologies of rapidly progressive glomerulonephritis. This condition presents with crescentic glomerulonephritis with little or no immunoglobulin staining and negative serological workup aside from a positive antineutrophil cytoplasmic autoantibody (ANCA). Typically, patients with pauci-immune CrGN have an underlying systemic small vessel vasculitis, but in rare cases, it presents without any known vasculitis or ANCA. Pauci-immune ANCA negative CrGN is often strictly isolated to the kidneys. In this case, we present a patient with ANCA negative, pauci-immune CrGN with severe diffuse alveolar hemorrhage. Case Presentation: A 66-year-old Hispanic woman with a past medical history of controlled hypertension presented with fatigue and dysphagia. On admission, her vital signs were significant for hypoxia on room air, and her physical exam was remarkable for crackles bilaterally. The initial laboratory results revealed anemia (hemoglobin 5.2 g/dL), hyperkalemia (6.3 mmol/L), elevated creatinine (4.50 mg/dL, with a baseline of 0.9mg/dL). Urinalysis showed moderate blood and urine protein (200 mg/dL). Urine microscopic examination showed 25-50 RBCs seen/high power field. The patient was admitted to ICU due to hypoxia, a computed tomography scan of the chest/abdomen/pelvis was obtained and revealed multifocal pulmonary consolidations. A blood transfusion was ordered. The patient began to have hemoptysis and subsequent bronchoscopy showed diffuse alveolar hemorrhage. ICU team proceeded to intubate her as the hemorrhage continued to worsen. Further workup revealed a positive anti-nuclear antibodies (ANA) of 1:40, but otherwise negative serologies including myeloperoxidase (MPO)-ANCA, glomerular basement membrane antibody, and anti-double stranded DNA. Kidney biopsy showed necrotizing glomerulonephritis with crescents and negative immunofluorescence. She was diagnosed with pauci-immune ANCA-negative vasculitis with associated diffuse alveolar hemorrhage and nephritis based on these results and was started on pulse-dose steroids. The patient was started on intravenous (IV) high-dose cyclophosphamide, which helped improved the overall clinical condition significantly. After creatinine began trending down and urine output improved, the patient was discharged on a regimen of daily oral cyclophosphamide and steroid taper. Patient oxygen requirements decreased and she was sent home with supplemental oxygen while requiring 3L/min of oxygen. Conclusion: Pauci-immune and ANCA-negative glomerulonephritis with concurrent diffuse alveolar hemorrhage is exceptionally rare. In this situation, medical management relied on clinical evidence from similar populations in the use of steroids and cyclophosphamide. This case report aims to shed more light on the clinical progression and management of this condition. Here we present a case of pulmonary-renal syndrome with biopsy-proven glomerulonephritis but without ANCA positive serologies.
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Avello A, Fernandez-Prado R, Santos-Sanchez-Rey B, Rojas-Rivera J, Ortiz A. Slo-Mo anti-neutrophil cytoplasmic antibody-associated renal vasculitis. Clin Kidney J 2021; 14:18-22. [PMID: 33564403 PMCID: PMC7857803 DOI: 10.1093/ckj/sfaa181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/14/2022] Open
Abstract
Nephrologists are familiar with severe cases of anti-neutrophil cytoplasmic antibodies-associated vasculitis (AAV) presenting as rapidly progressive glomerulonephritis. However, less is known about AAV with slowly progressive renal involvement. While its existence is acknowledged in textbooks, much remains unknown regarding its relative frequency versus more aggressive cases as well as about the optimal therapeutic approach and response to therapy. Moreover, this uncommon presentation may be underdiagnosed, given the scarce familiarity of physicians. In this issue of Clinical Kidney Journal, Trivioli et al. report the largest series to date and first systematic assessment of patients with AAV and slowly progressive renal involvement, defined as a reduction in estimated glomerular filtration rate (eGFR) of 25-50% in the 6 months prior to diagnosis after excluding secondary causes. Key findings are that slowly progressive AAV may be less common than previously thought, although it still represents the second most common presentation of renal AAV, it usually has a microscopic polyangiitis, anti-myeloperoxidase, mainly renal phenotype in elderly individuals, diagnosis may be late (over one-third of patients had end-stage kidney disease at diagnosis), clearly identifying an unmet need for physician awareness about this presentation, but those not needing renal replacement therapy at diagnosis still responded to immunosuppression.
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Affiliation(s)
- Alejandro Avello
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Raul Fernandez-Prado
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Begoña Santos-Sanchez-Rey
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Jorge Rojas-Rivera
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
| | - Alberto Ortiz
- Department of Medicine, School of Medicine, IIS-Fundación Jiménez Diaz, Division of Nephrology and Hypertension, Universidad Autónoma de Madrid, Madrid, Spain
- Red de Investigación Renal (REDINREN), Instituto Carlos III-FEDER, Madrid, Spain
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Neurologic Manifestations of Systemic Disease: Peripheral Nervous System. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00631-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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4
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Soyez B, Borie R, Menard C, Cadranel J, Chavez L, Cottin V, Gomez E, Marchand-Adam S, Leroy S, Naccache JM, Nunes H, Reynaud-Gaubert M, Savale L, Tazi A, Wemeau-Stervinou L, Debray MP, Crestani B. Rituximab for auto-immune alveolar proteinosis, a real life cohort study. Respir Res 2018; 19:74. [PMID: 29695229 PMCID: PMC5918901 DOI: 10.1186/s12931-018-0780-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/16/2018] [Indexed: 12/16/2022] Open
Abstract
Background Whole lung lavage is the current standard therapy for pulmonary alveolar proteinosis (PAP) that is characterized by the alveolar accumulation of surfactant. Rituximab showed promising results in auto-immune PAP (aPAP) related to anti-GM-CSF antibody. Methods We aimed to assess efficacy of rituximab in aPAP in real life and all patients with aPAP in France that received rituximab were retrospectively analyzed. Results Thirteen patients were included. No patients showed improvement 6 months after treatment, but, 4 patients (30%) presented a significant decrease of alveolar-arterial difference in oxygen after 1 year. One patient received lung transplantation and one patient was lost of follow-up within one year. Although a spontaneous improvement cannot be excluded in these 4 patients, improvement was more frequent in patients naïve to prior specific therapy and with higher level of anti-GM-CSF antibodies evaluated by ELISA. No serious adverse event was evidenced. Conclusions These data do not support rituximab as a second line therapy for patients with refractory aPAP.
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Affiliation(s)
- Berenice Soyez
- Service de Pneumologie A, DHU FIRE, centre de référence constitutif des maladies pulmonaires rares, Hôpital Bichat, APHP, 46 rue Henri Huchard 75877 Paris CEDEX, 18, Paris, France.,OrphaLung, Lyon, France.,Service de Pneumologie, Hôpital de la Pitié Salpetrière, APHP, Paris, France
| | - Raphael Borie
- Service de Pneumologie A, DHU FIRE, centre de référence constitutif des maladies pulmonaires rares, Hôpital Bichat, APHP, 46 rue Henri Huchard 75877 Paris CEDEX, 18, Paris, France. .,OrphaLung, Lyon, France. .,INSERM, Unité 1152, Université Paris Diderot, Paris, France.
| | - Cedric Menard
- Service d'Immunologie, Thérapie Cellulaire et Hématopoïèse, CHU Pontchaillou, Rennes, France
| | - Jacques Cadranel
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, Hôpital Tenon, APHP, Paris, France
| | - Leonidas Chavez
- Service de Pneumologie, Centre de compétences des maladies pulmonaires rares, CHU Grenoble-Alpes, Grenoble, France
| | - Vincent Cottin
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre national de référence des maladies pulmonaires rares, Hôpital Louis Pradel, Université Claude Bernard Lyon 1, Lyon, France
| | - Emmanuel Gomez
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de compétences des maladies pulmonaires rares CHRU Nancy, Nancy, France
| | - Sylvain Marchand-Adam
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de compétences des maladies pulmonaires raresCHRU de Tours, Tours, France
| | - Sylvie Leroy
- OrphaLung, Lyon, France.,FHU Oncoage, Service de Pneumologie, Centre de compétence des maladies pulmonaires rares, Université Côte d'Azur, CHU de Nice, Nice, France
| | - Jean-Marc Naccache
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, Hôpital Tenon, APHP, Paris, France
| | - Hilario Nunes
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, Hôpital Avicenne, APHP, Bobigny, France
| | - Martine Reynaud-Gaubert
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de compétence des maladies pulmonaires rares, Hôpital Nord, Marseille, France
| | - Laurent Savale
- Service de Pneumologie, Centre de référence de l'hypertension pulmonaire, Hôpital Bicêtre, APHP, Le Kremlin Bicêtre, France
| | - Abdellatif Tazi
- Service de Pneumologie, Hôpital Saint-Louis, APHP, Paris, France
| | - Lidwine Wemeau-Stervinou
- OrphaLung, Lyon, France.,Service de Pneumologie, Centre de référence constitutif des maladies pulmonaires rares, CHRU de Lille, Lille, France
| | | | - Bruno Crestani
- Service de Pneumologie A, DHU FIRE, centre de référence constitutif des maladies pulmonaires rares, Hôpital Bichat, APHP, 46 rue Henri Huchard 75877 Paris CEDEX, 18, Paris, France.,OrphaLung, Lyon, France.,INSERM, Unité 1152, Université Paris Diderot, Paris, France
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5
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Thiel J, Rizzi M, Engesser M, Dufner AK, Troilo A, Lorenzetti R, Voll RE, Venhoff N. B cell repopulation kinetics after rituximab treatment in ANCA-associated vasculitides compared to rheumatoid arthritis, and connective tissue diseases: a longitudinal observational study on 120 patients. Arthritis Res Ther 2017; 19:101. [PMID: 28521808 PMCID: PMC5437549 DOI: 10.1186/s13075-017-1306-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/02/2017] [Indexed: 01/24/2023] Open
Abstract
Background B cell depletion with rituximab (RTX) is approved for treatment of rheumatoid arthritis (RA) and ANCA-associated vasculitides (AAV). Recently, RTX has been shown to be effective in AAV maintenance therapy, but an optimal RTX treatment schedule is unknown and the time to B cell repopulation after RTX has not been studied. Methods Retrospective single-center analysis of B cell repopulation in patients with AAV, RA or connective tissue disease (CTD) treated with RTX. Results Beginning B cell repopulation within the first year after RTX treatment was observed in 93% of RA and 88% of CTD patients. Only 10% of patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) and no patient with eosinophilic granulomatosis with polyangiitis (EGPA) showed B cell repopulation within this time. Median time of B cell depletion was 26 months in GPA/MPA, and 21 months in EGPA compared to 9 months in RA, and 8 months in CTD (p < 0.0001). In 25 AAV-patients B cell depletion lasted for at least 44 months. There was a significant decline in serum immunoglobulin concentrations in GPA/MPA patients, but not in patients with RA or CTD. Significantly more GPA/MPA patients developed hygogammaglobulinemia (IgG <7 g/L) compared to patients with RA or CTD. Conclusions In contrast to RA and CTD, in AAV RTX induces long-lasting depletion of B cells that is associated with decreased antibody production. This observation points toward potential defects in the B cell compartment in AAV that are unmasked by immunosuppressive treatment and has important implications for the design of maintenance treatment schedules using RTX.
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Affiliation(s)
- Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Marta Rizzi
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Marie Engesser
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Ann-Kathrin Dufner
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Arianna Troilo
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Raquel Lorenzetti
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Reinhard E Voll
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Hugstetterstrasse 55, 79106, Freiburg, Germany.
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Demiselle J, Auchabie J, Beloncle F, Gatault P, Grangé S, Du Cheyron D, Dellamonica J, Boyer S, Beauport DT, Piquilloud L, Letheulle J, Guitton C, Chudeau N, Geri G, Fourrier F, Robert R, Guérot E, Boisramé-Helms J, Galichon P, Dequin PF, Lautrette A, Bollaert PE, Meziani F, Guillevin L, Lerolle N, Augusto JF. Patients with ANCA-associated vasculitis admitted to the intensive care unit with acute vasculitis manifestations: a retrospective and comparative multicentric study. Ann Intensive Care 2017; 7:39. [PMID: 28382598 PMCID: PMC5382116 DOI: 10.1186/s13613-017-0262-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/23/2017] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Data for ANCA-associated vasculitis (AAV) patients requiring intensive care are scarce. METHODS We included 97 consecutive patients with acute AAV manifestations (new onset or relapsing disease), admitted to 18 intensive care units (ICUs) over a 10-year period (2002-2012). A group of 95 consecutive AAV patients with new onset or relapsing disease, admitted to two nephrology departments with acute vasculitis manifestations, constituted the control group. RESULTS In the ICU group, patients predominantly showed granulomatosis with polyangiitis and proteinase-3 ANCAs. Compared with the non-ICU group, the ICU group showed comparable Birmingham vasculitis activity score and a higher frequency of heart, central nervous system and lungs involvements. Respiratory assistance, renal replacement therapy and vasopressors were required in 68.0, 56.7 and 26.8% of ICU patients, respectively. All but one patient (99%) received glucocorticoids, 85.6% received cyclophosphamide, and 49.5% had plasma exchanges as remission induction regimens. Fifteen (15.5%) patients died during the ICU stay. The following were significantly associated with ICU mortality in the univariate analysis: the need for respiratory assistance, the use of vasopressors, the occurrence of at least one infection event in ICU, cyclophosphamide treatment, sequential organ failure assessment at admission and simplified acute physiology score II. After adjustment on sequential organ failure assessment or infection, cyclophosphamide was no longer a risk factor for mortality. Despite a higher initial mortality rate of ICU patients within the first hospital stay (p < 0.0001), the long-term mortality of hospital survivors did not differ between ICU and non-ICU groups (18.6 and 20.4%, respectively, p = 0.36). Moreover, we observed no renal survival difference between groups after a 1-year follow-up (82.1 and 80.5%, p = 0.94). CONCLUSION This study supports the idea that experiencing an ICU challenge does not impact the long-term prognosis of AAV patients.
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Affiliation(s)
- Julien Demiselle
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, 49933, Angers Cedex 9, France.,Néphrologie-Dialyse-Transplantation, CHU Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Johann Auchabie
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - François Beloncle
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Philippe Gatault
- Service de Néphrologie et Immunologie Clinique, CHRU Tours, Tours, France
| | - Steven Grangé
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Damien Du Cheyron
- Service de Réanimation Médicale, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14033, Caen Cedex 9, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, Archet 1 University Hospital, Route de St Antoine, CS 23079, 06202, Nice, France
| | - Sonia Boyer
- Medical Intensive Care Unit, Archet 1 University Hospital, Route de St Antoine, CS 23079, 06202, Nice, France
| | - Dimitri Titeca Beauport
- Medical Intensive Care Unit, Amiens University Medical Center, 80054, Amiens, Cedex 1, France
| | - Lise Piquilloud
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, 49933, Angers Cedex 9, France.,Service de Médecine Intensive Adulte et Centre des Brûlés, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Julien Letheulle
- Service de Réanimation Médicale, Hôpital Pontchaillou, CHU Rennes, 2 rue Henri Le Guilloux, 35033, Rennes Cedex, France
| | - Christophe Guitton
- Medical Intensive Care Unit, Hôtel-Dieu, University Hospital of Nantes, 30 bd Jean Monnet, 44093, Nantes, France.,UMR 1064, Inserm, 30 bd Jean Monnet, 44093, Nantes, France
| | - Nicolas Chudeau
- Service de Reanimation Medico-Chirurgicale, Centre Hospitalier du Mans, 194 Avenue Rubillard, 72037, Le Mans, France
| | - Guillaume Geri
- Service de Réanimation Médicale, Hôpital Cochin, Paris, France
| | - François Fourrier
- Réanimation, Centre de Réanimation Polyvalente, Hôpital Roger Salengro, CHRU de Lille, Lille, France
| | - René Robert
- Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France
| | - Emmanuel Guérot
- Service de Réanimation Médicale, Hôpital Européen Georges Pompidou, Paris, France
| | - Julie Boisramé-Helms
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Université de Strasbourg, Strasbourg, France
| | - Pierre Galichon
- APHP, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, Paris, France
| | | | - Alexandre Lautrette
- Service de Réanimation Médicale Polyvalente, CHU Gabriel Montpied, 58 rue Montalembert, 63000, Clermont-Ferrand, France
| | - Pierre-Edouard Bollaert
- Service de Réanimation Médicale, CHU de Nancy Hôpital Central, 29 Avenue de Lattre de Tassigny, 54035, Nancy Cedex, France
| | - Ferhat Meziani
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Université de Strasbourg, Strasbourg, France
| | - Loïc Guillevin
- Département de Médecine Interne, Assistance Public des Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Nicolas Lerolle
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, 49933, Angers Cedex 9, France.
| | - Jean-François Augusto
- Néphrologie-Dialyse-Transplantation, CHU Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
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Eleftheriou D, Brogan PA. Therapeutic advances in the treatment of vasculitis. Pediatr Rheumatol Online J 2016; 14:26. [PMID: 27112923 PMCID: PMC4845429 DOI: 10.1186/s12969-016-0082-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 04/04/2016] [Indexed: 02/06/2023] Open
Abstract
Considerable therapeutic advances for the treatment of vasculitis of the young have been made in the past 10 years, including the development of outcome measures that facilitate clinical trial design. Notably, these include: a recognition that some patients with Kawasaki Disease require corticosteroids as primary treatment combined with IVIG; implementation of rare disease trial design for polyarteritis nodosa to deliver the first randomised controlled trial for children; first clinical trials involving children for anti-neutrophil cytoplasmic antibody (ANCA) vasculitis; and identification of monogenic forms of vasculitis that provide an understanding of pathogenesis, thus facilitating more targeted treatment. Robust randomised controlled trials for Henoch Schönlein Purpura nephritis and Takayasu arteritis are needed; there is also an over-arching need for trials examining new agents that facilitate corticosteroid sparing, of particular importance in the paediatric population since glucocorticoid toxicity is a major concern.
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Affiliation(s)
- Despina Eleftheriou
- ARUK centre for Paediatric and Adolescent Rheumatology, Institute of Child Health and Great Ormond St Hospital NHS Foundation Trust, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Paul A Brogan
- Department of Paediatric Rheumatology, Institute of Child Health and Great Ormond St Hospital NHS Foundation Trust, 30 Guilford Street, London, WC1 E1N, UK
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8
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Shah S, Geetha D. Place in therapy of rituximab in the treatment of granulomatosis with polyangiitis and microscopic polyangiitis. Immunotargets Ther 2015; 4:173-83. [PMID: 27471722 PMCID: PMC4918256 DOI: 10.2147/itt.s55516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Granulomatosis with polyangiitis and microscopic polyangiitis are small vessel vasculitides characterized by circulating antineutrophil circulating antibodies. Standard treatment for active severe disease has consisted of cyclophosphamide with glucocorticoids with or without plasmapheresis, which achieves approximately 75% sustained remission, but carries significant adverse effects such as malignancy, infertility, leukopenia, and infections. The role of B cells in the pathogenesis of anti-neutrophil circulating antibodies-associated vasculitis has been established, and as such, rituximab, a monoclonal anti-CD20 antibody, has been studied in treatment of active granulomatosis with polyangiitis and microscopic polyangiitis (induction) and in maintaining remission. Rituximab has been shown to be effective in inducing remission in several retrospective studies in patients with refractory disease or cyclophosphamide intolerance. The RAVE and RITUXVAS trials demonstrated rituximab is a noninferior alternative to standard cyclophosphamide-based therapy; however, its role in elderly patients and patients with severe renal disease warrants further investigation. Rituximab has been compared with azathioprine for maintaining remission in the MAINRITSAN trial and may be more efficacious in maintaining remission in patients treated with cyclophosphamide induction. Rituximab is not without risks and carries a similar adverse event risk rate as cyclophosphamide in randomized control trials. However, its use can be considered over cyclophosphamide in patients who have relapsing or refractory disease or in young patients seeking to preserve fertility.
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Affiliation(s)
- Shivani Shah
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Duvuru Geetha
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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